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UNITED STATES PUBLIC HEALTH SERVICE 

RUPERT BLUE, Surgeon General 



MENTAL EXAMINATIONS OF 
SCHOOL CHILDREN 

THE SCHOOL AS A FACTOR 
IN THE MENTAL HYGIENE 
OF RURAL COMMUNITIES 



BY 

TALIAFERRO CLARK 

Surgeon, United States Public Health Service 



REPRINT No. 358 

FROM THE 

PUBLIC HEALTH REPORTS 

August 25, 1916 
(Pages 2265-2271) 




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WASHINGTON 
GOVERNMENT PRINTING OFFICE 






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MENTAL EXAMINATIONS OF SCHOOL CHILDREN. 






THE SCHOOL AS A FACTOR IN THE MENTAL HYGIENE OF RURAL COMMUNITIES. 

By Tauafeeko Clark, Surgeon, United States Public Health Service. 

In the course of investigations of school hygiene by the United 
States PubUc Health Service during the past year and a half, mental 
examinations have been made of over 18,000 school children in four 
States. As nearly all of the children examined resided in rural dis- 
tricts, these studies relate more particularly to the rural school child. 

Retardation. — The problems of mental hygiene observed, while 
closely related to those existing in urban communities, present dis- 
tinct characteristics. The most outstanding of these problems are 
those connected with the large number of mentally retarded children 
observed. 

While all the collected data bearing on mental retardation have 
not been compiled, the studies being still in progress, compilations 
have been made in the case of the rural school population of one 
entire coimty.^ The average attendance in the rural schools of- this 
coimty was 2,512. The number of children who were examined 
mentally was 2,185. The results of these examinations, therefore, 
should be representative of the district in question. Of these 2,185 
children, 8.7 per cent were retarded as follows: Children of 6 and 7 
7 years of age, retarded two years; 8 and 9 years of age, two and 
three years; 10 and 11 years of age, three and four years; 14 and 15 
years of age, five years; and 16 to 17 years of age, retarded six years 
mentally. 

The average retardation of these children in school work as graded 
by teachers was 1.28 years for girls and 1.5 years for boys. In other 
words, the total retardation in school work amounted to 268.27 
school years. 

Furthermore, intensive studies were made of the physical condition 
and school environment of these children. The following physical 
defects were recorded: Of the retarded girls, 35.5 per cent were under- 
sized, 58.8 per cent had noticeable visual defects, 26.4 per cent had 
defects of hearing, 17.6 per cent had two or more defective teeth, 2.9 
per cent had enlarged tonsils, and an additional 1.7 per cent had 
enlarged tonsils associated with adenoids. 

Of the boys, 38 per cent were undersized, 47 per cent had notice- 
able defects of vision (of which number 19 had confused color sense), 
34 per cent had defective hearing, 17 per cent had defective teeth, 
and 6 per cent had adenoids and enlarged tonsils. 

1 Read before the Section on Feeble-mindedness and Insanity, National Conference of Charities and 
Corrections, Indianapolis, Ind., May 15, 1916. Reprint from the Public Health Reports, vol, 31, No. 34, 
Aug. 25, 1916, pp. 2265-2271. 

3 Public Health Bulletin No. 77. 

2 
59859°— 16 ^* OL D. 

NOV : ^ iQi^- 



MENTAL EXAMINATIONS OF SCHOOL CHILDREN. 3 

These children were not feeble-minded. A clear distmction must 
be made between these two conditions for a proper appreciation of 
the role of retardation in mental deficiency. The rate of intellectual 
development varies at different age periods. In very young children 
the rate is relatively rapid. In fact, it can be easily observed without 
special methods. As the child grows older, however, the progress of 
bitellectual development from year to year is less easily detected, so 
that between the ages of 12 and 13 it can not be recognized. In the 
case of older children, therefore, the correlation of retardation and 
permanent mental deficiency is relatively easy. In other words, the 
greater the discrepancy obtaining between the chronological and 
actual mental ages, the more definitely it may be asserted that the 
child is feeble-minded and that his intelligence will never be greater, 
than that of a child when he becomes an adult. This is due to the 
improbability that a great amount of retardation wiU be overcome 
in a short time intervening before maturity and at a lessened rate of 
mental progress. 

In the case of very young children, however, one of two things may 
take place. First, the retardation may be temporary only. The an- 
nual increments of intellectual development may be so great as to 
overcome the retardation in the longer period which must elapse be- 
fore maturity. On the other hand, mental development may remain 
stationary or develop so slowly that the individual still presents the 
mentality of a child when the adult stage is reached. 

Rural children are exposed to influences causing retardation that 
are quite distinct from those affecting childi*en in urban communi- 
ties. Broadly speaking, these influences may bo considered from 
the standpoint of (1) sanitation and (2) education. 

(1) School surveys have shown that 12 per cent of the population 
in certain sections of our country is afflicted with, trachoma. The 
amount of mental retardation observed in these sections is very 
great, due to the fact that the damage to vision caused by this disease 
hampers intellectual training. 

It is known that there are many thousands of people suffering from 
hookworm disease in this country. It is common experience that 
cliildren suffering from hookworm mfection show evidences of mental 
retardation. 

Furthermore, mental retardation is frequently associated with cer- 
tain nutritional disorders. Of particular interest in this connection is 
pellagra, which is a nutritional disorder due to an improperly arranged 
dietary. It is estimated that there are 75,000 people in this country 
who are suffering from pellagra, a large proportion of whom are chil- 
dren. Not only is this disease associated with mental retardation, but 
from 4 to 10 per cent of pellagrins eventually become insane. 



4 MENTAL EXAMINATION-6 OF SCHOOL CHILDREN. 

Finally, certain physical defects, especially those involving the 
organs of sight and hearing, operate to cause retardation. Failure 
to provide for the health supervision of the school children, which 
is so common in rural communities, is largely responsible for the 
continuance of a number of these defects, which react injuriously on 
mental functioning. 

(2) Of the educational influences operating to cause mental retar- 
dation may be mentioned the school environment, the sanitation of 
the school building, the arrangement and equipment of classrooms, 
the maintenance of too large a number of children in different grades 
in one-room schools, and faulty teaching methods. 

Eighty-nine per cent of the rural schools inspected in the county 
previously referred to were one-story structures, and 57 per cent 
were more than 20 years old. Adjustable desks were found in only 
9.5 per cent of the classrooms, 41.1 per cent of the classrooms were 
heated by closed stoves, 27.6 pei-cent were without aids to ventila- 
tion, and the illumination was from the right direction in only 42.2 
per cent. 

Finally, retardation is itself a cause of retardation. The home en- 
vironment and the mental attitude of parents who are themselves 
retarded are potent factors in the mental retardation of their children. 
Furthermore, the presence of a number of retarded children in a class 
exerts a hampering effect on the mental advancement of the class as a 
whole. This condition is very common in rural schools, due to the 
absence of facilities for the formation of special classes for the training 
of children in need of individualized instruction. 

Mention has been made of the numbers of retarded individuals 
observed in communities where certain endemic diseases and nutri- 
tional disorders are common. When a child retarded by hookworm 
disease has been cured, he has promptly passed to higher grade. 
Again, instances are not lacking to show that the longer the infection 
persists in these cases the more permanent the effects of retardation 
are likely to be from the standpoint of both physical and mental 
development. It is clear, therefore, that constitutional conditions 
operating to produce mental retardation, unless removed, may 
finally bring about permanent mental impairment. 

Of more general interest, however, because of the more extended 
field of operation, is the r61e of retardation from causes not clearly 
understood in inducing feeble-mindedness. The investigations of 
HoUey 1 show that the tendency is for men and women to marry those 
who are approximately of the same educational level. The inter- 
marriage of men and women who have become discouraged through 
retardation and have quit school with but meager educational attain- 

1 The Relationship between Persistence in School and Home Conditions. Charles Elmer HoUey. The 
Fifteenth Yearbook of the National Society for the Study of Education. 



MENTAL EXAMINATIONS OF SCHOOL CHILDREN. 5 

ments is quite common. The poor judgment so noticeable in indi- 
viduals of this type, the weakened will, and the ready yielding to 
desires frequently bring about unfortunate marriage selections, the 
formation of vicious and intemperate habits, and increase in venereal 
affections, influences that are largely responsible for social and 
economic conditions provocative of feeble-mindedness. 

Feehle-mindedness. — The percentage of feeble-minded persons in 
the general population is not known. It has been placed as high as 
4 per cent by some observers. In this respect each community is 
a problem in itself. This is because of the modification of hereditary 
and environmental influences by immigration and geographical 
location.. 

The percentage of feeble-mindedness observed in the course of 
the investigations of the Pubhc Health Service varied from 0.3 to 
1.1 per cent, according to locality. Underphysical development was 
not found frequently associated with exceptional retardation — feeble- 
mindedness. In the case of feeble-minded, 57 per cent of the girls 
and 42.8 per cent of the boys were above the average physical de- 
velopment determined for the county. Furthermore, 42.8 per cent 
of the girls had visual defects, 14.2 per cent had defects of hearing, 
and 2.9 per cent had enlarged tonsils. Of the boys, 34.2 per cent 
had visual defects, 57.1 per cent defects of hearing, and 7.1 per cent 
enlarged tonsils. These observations seem more in accord with 
what might be expected in the case of feeble-minded children. It is 
natural to suppose that these children simply vegetate — i. e., grow 
rapidly in a fairly good environment. 

Constitutional inferiority. — ^A boy was observed in a rural school 
who was noisy, vain, said to be cruel to animals, inchned to impose 
on yoimger children, and given to lying and petty pilfering. Children 
of this type are termed by psychologists ''constitutionally inferior" 
and are of average intelligence. Quite early in Hfe, however, they 
give evidences of a perverted moral sense that makes them potential 
criminals in a bad environment. The number of such childem 
found in any one community is not large; nevertheless, they are 
found in nimabers suflScient to make them a serious problem from 
an educational and sociological standpoint. Especially is this true 
of rural communities where compulsory school attendance is re- 
quired by law but where no provision is made for the care and train- 
ing of defective children. 

Owing to the tendency to imitation exhibited by young children, 
the compulsory school attendance of the constitutionally inferior 
is a menace to the moraUty of the community far greater than 
seems to be warranted by their number. The presence of such 
children in the general classes is undesirable, yet it is unwise to throw 
them back on the community without the hope of future training or 



6 MENTAL EXAMINATIONS OF SCHOOL CHILDREN. 

restraint. To do so will but crystallize vicious tendencies which 
make of them a menace to society. The school offers that ready 
opportunity for the early recognition of children of this type which 
is so desirable for the successful apphcation of necessary training 
methods. 

Insanity and epilepsy. ^During our investigations several insane 
children and a number of others with a marked psychopathic tendency 
have been noted. The occurrence of insanity in children has received 
but little recognition until within comparatively recent years. The 
early recognition of psychopathic tendencies is of vast importance 
from the standpoint of mental hygiene. It must be remembered 
that children who exhibit these tendencies have sick minds, just as 
other children have sick bodies, which require appropriate treat- 
ment. Ultimate recovery in cases of this kind depends largely on 
the prompt recognition of symptoms and early apphcation of remedial 
measures. Continued studies of this character among school children 
are demanded to show the necessity of this form of health super- 
vision for the protection of the mental health of communities. 

An appreciable number of epileptic children have been observed 
in the course of these surveys of rural schools. The epileptic school 
child requires careful supervision because of the not infrequent 
occurrence of temporary mental disturbances in close association 
with an attack, during which serious bodily injury may be done to 
other children. Here, again, rural districts are sadly handicapped 
by the absence of medical school inspections and facihties for the 
care of epileptic children. 

Our investigations have demonstrated the value of the school as 
an instrument to promote the mental health of rural communities, 
and have indicated a number of ways in which it may be utilized 
for this purpose. Of these maybe mentioned measures intended (1) 
to determine the prevalence of mental deficiency, (2) to promote 
rural sanitation, (3) to train the individual child in the formation 
of correct habits. 

(1) Our experience has shown that it is necessary to confront the 
average rural community with a specific problem before the coopera- 
tion of the whole community can be obtained in the application of 
measures intended to meet a particular situation. It is of prime 
importance, therefore, to determine the number of mental defectives 
in a given community. Because of the close association between the 
home and the school, a mental examination of school children is the 
most practical means by which the prevalence of mental deficiency 
may be determined. 

It is very desirable in this connection, however, to adopt uniform 
methods of procedure. For example, the considerable variation in 
the percentage of f eeble-mindedness in the general popidation, as given 



MENTAL EXAMINATIONS OF SCHOOL CHILDREN. 7 

by different observers, is too great to be accounted for by differences 
in local influences. These variations are due, in large part, to (a) the 
absence of a definite recognized feeble-minded ''complex" and (b) the 
need of practical uniform tests of certain mental functions. 

The proper classifications of persons who are patently feeble-minded 
is not difficult. It is a far different proposition in border-line cases, 
however, to say just when retardation ceases and feeble-mindedness 
begins. There is need for far greater diagnostic precision in these 
cases than obtains under present conditions to bring about uniform 
results. As it is, the classification of a number of border-hne cases 
depends largely on the personal equation and experience of individual 
observers. 

Furthermore, our investigations have shown the desirability of 
employing psychologists having biological training to conduct exami- 
nations of this character. In studies of mental deficiency a distinc- 
tion must be made between acquired mental defects and those that 
are transmissible. For example, children who become defectives 
through traumatism, severe organic lesions, and more or less prolonged 
action of certain infections and improper dietaries are not defective 
in the true meaning of the term. 

(2) Not only does the continued presence of endemic diseases entail 
great economic losses to communities where they prevail by reducing 
the physical efficiency of a great part of the population, but they are 
also accompanied by a similar reduction in mental efficiency. These 
harmful infiuences continue to exist because of the general lack of 
information so common in rural communities concerning their cause 
and prevention. In a number of instances it is a difficult matter to 
secure the cooperation of the adult population, which is set and fixed 
in its habits, in measures intended to improve the community health. 
Health supervision of school children not only gives valuable informa- 
tion concerning the prevalence of these conditions, but it also exercises 
an educational effect on the rising generation, through whom the sani- 
tary redemption of these communities is largely to be brought about. 

The control of hookworm disease is a, matter of personal hygiene 
and community sanitation. The school is an effective agent for the 
demonstration of measures for its control, and in addition offers 
exceptional facihties for the early detection of hookworm sufferers 
and their prompt cure, both of which are necessary to prevent per- 
manent mental impairment. 

Mention has been made of the effect of poor nutrition on mental 
development in connection with pellagra. The ill effects of faulty 
feeding in infancy and early childhood on the physical and mental 
health are well recognized. It was not discovered imtil recently, 
however, that food value means much more than its estimation in 
terms of calories. It is now known that a diet sufficient to supply the 



8 MENTAL EXAMINATIONS OF SCHOOL CHILDREN. :■ 

demands of normal metabolism must contain a due proportion of ;; 
what are called ^'vitamines." I 

Vitamines occur in very small amoimts and in varying proportions H 
in different foodstuffs, a fact which must be taken into consideration 
in arranging a dietary for the cure and prevention of nutritional dis- 
orders. The mental hygienist is deeply interested in the school, there- 
fore, as a factor in the prevention of these disorders through the teach- ;;; 
ing of food preparation and food values and the extension of this ■'■ 
knowledge to the home. 

(3) It has been asserted that a large percentage of school children 
are predisposed to mental '^ complexes" usually found associated with 
what are now considered functional disorders of the mind. Incorrect 
habits of thought and f eehng in the child, unless corrected, are possible ^ 
causes of the failure of the child later in Hfe properly to adjust himseK " 
to his environment. We have observed in rural communities children 
who present one or more of the symptoms usually enumerated as form- | 
ing a mental '^complex" in such numbers that grave doubts are raised 
as to the correctness of this general form of a posteriori reasoning. 
Certainly there is need of something other than indefinite statements .:: 
regarding the relation between personality and psychosis. The most jii 
practical plan for supplying this want, I believe, is the study of per- lii 
sonahty in developing school children, somewhat after the manner jH 
outhned by Hoch.^ Data so collected and filed for future reference ^ 
will be of the greatest value in the correlation of certain mental traits % 
and psychoses appearing later in hfe. |: 

Studies of this character also serve to draw attention to the milder ^ 
forms of abnormality which, when neglected, crystallize into faulty | 
habits productive of grave consequences to the mental health. jji 

To be effective the teaching of correct ''habit formation" should iii 
begin in the home at an age earher than that represented by the school jjl 
period. Unfortunately, this is not of general apphcation in most | 
rural districts, where the tendency to the formation of incorrect habits Iji 
is largely due to the comparative isolation of f amiHes and the lack of jjj 
contact with the broadening influences of the outside world. The | 
school, therefore, stands in a very definite relation to such communi- || 
ties in supplying the training for the prevention of faulty habits which 
so materially reduce individual efficiency. 



1 A Guide to the Descriptive Study of the Personality. Dr. August Hoch and Dr. George S. Amsden, !i!i 
State Hospital Bulletin (N. Y.), November, 1913. ji|i 



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